Provider Demographics
NPI:1275163776
Name:PETZ, MICHELLE RENE (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENE
Last Name:PETZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6333 S BINGHAM AVE
Mailing Address - Street 2:
Mailing Address - City:NEWAYGO
Mailing Address - State:MI
Mailing Address - Zip Code:49337-9731
Mailing Address - Country:US
Mailing Address - Phone:231-519-7555
Mailing Address - Fax:
Practice Address - Street 1:25 W MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1186
Practice Address - Country:US
Practice Address - Phone:231-519-7555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010896821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801089682OtherSTATE OF MI